E/M service + injection for different diagnosis

Q If a physician administers an injection as part of an office visit, can the injection code be billed in addition to the office visit code? Is this permissible under any circumstance, or only when the diagnosis associated with the injection is different from the primary diagnosis associated with the office visit? For example, if a patient comes in for a sinus infection and I administer an injection of Celestone for the sinus infection, can 90772 be billed along with 99213? What if the sinus infection was the primary focus of the visit but I administer a B12 shot for anemia?

A You can report both codes as long as the injection is a significant and separately identifiable service. In such cases, modifier 25 should be attached to the E/M code. It may also be appropriate to bill for the injectable medication using the proper J code. Different diagnoses are not required when reporting an E/M service on the same date as a procedure, according to the Medicare Claims Processing Manual, Chapter 12, Section 30.5 (download it at http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf).

Nurse house calls

Q My nurse, an LPN, visited a homebound patient to evaluate her and perform venipuncture. Should I bill 99211, home services code 99347 or something different? Is 99347 to be used only when physicians provide the service?

A Only physicians and certain nonphysician clinicians (e.g., physician assistants or nurse practitioners) acting within the scope of their license should report code 99347. For Medicare patients, services provided by an LPN without direct physician supervision would be covered only when a home health agency is not available to provide the services and all other conditions related to the incident-to guidelines are met. (See the Medicare Benefit Policy Manual, Chapter 15, Section 60.4.) Private payer policies may differ but often align with Medicare. Code 36415 is indicated for reporting of routine venipuncture.

Code pair references

Q Where can I find information regarding which codes are separately payable when reported with modifiers?

A The National Correct Coding Initiative (NCCI) edits are a commonly referenced tool for identifying code pairs that may require a modifier. The files may be downloaded from the Centers for Medicare & Medicaid Services Web site. Under “Service Type,” click on the link titled “Medicine Evaluation and Management Services” and select both files listed under “Downloads.” These are zipped files that will need to be unzipped on your computer before you can access them.

The Excel spreadsheet titled “Column 1/Column 2 Edits” (see a small portion of it below) contains two types of code pair edits. One type contains a column 2 (component) code, which CMS has determined is an integral part of the column 1 (comprehensive) code and not separately payable in most cases. The other type contains code pairs that CMS has determined should generally not be reported together for other reasons, with one code assigned to column 1 and the other code assigned to column 2. If both codes of a code pair edit are billed by the same provider for the same patient on the same date of service, the column 1 code is paid. In some cases, both codes will be paid if a modifier is appended to the column 2 code. The far right column in the spreadsheet indicates the column 2 codes that may be payable with a modifier.

The “Mutually Exclusive Edits” spreadsheet contains edits consisting of two codes that CMS has determined in most cases cannot reasonably be performed together based on the code definitions or anatomic considerations. Each edit consists of a column 1 and column 2 code. If the two codes of an edit are billed by the same provider for the same beneficiary on the same date of service, the column 1 code is paid – unless a modifier justifies payment of the column 2 code too, as indicated in the spreadsheet.

Additional resources, including a link to frequently asked questions about the NCCI, are available here. Keep in mind that the code pairs in these files are established by the Centers for Medicare & Medic-aid Services. Private payers may adopt code edits that vary from the NCCI and may or may not publish the edits; check your payer’s Web site for this information.

NATIONAL CORRECT CODING INITIATIVE: CODE PAIRS REFERENCE

The image below shows how information about coding edits is displayed in files that can be downloaded from the CMS Web site. The tables can be used to identify Medicare-bundled codes that do not require modifiers and those that can be submitted separately with modifiers.

Editor’s note: While we attempt to provide accurate and useful advice, payers may not accept the coding recommended. Refer to current CPT and ICD-9 manuals and the Documentation Guidelines for Evaluation and Management Services for the most up-to-date information.

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Send questions and comments to fpmedit@aafp.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.